RESEARCH into rheumatic heart disease has progressively yielded a series of important facts and a good deal that is still speculative. It has been shown that many tissues, especially vascular structures, throughout the body are injured in attacks of rheumatic fever, and that the most serious damage occurs in the heart, to the myocardium and to its valves. It is generally considered now to have been conclusively shown that infections of body tissues with type A hsemolytie streptococci play a causative and key role in the pathogenesis of this disease, but only a small proportion of human beings infected with type A streptococci develop rheumatic heart disease. It is also widely held that the rheumatic lesions in the myocardium, including the so-called Aschoff bodies, are non-myogenic lesions of the connective tissue and do not involve the heart muscle fibres. However, G. E. Murphy,' in a long and very detailed paper, subsequently reprinted as a monograph,\" has set out to demonstrate that this last-mentioned interpretation is not correct, and that it is the heart muscle and plain muscle fibres which are affected. He was able to produce typical cardiac changes in a small proportion of rabbits with multiple focal infections due to type A heemolytie streptococci, and these gave material for study at various stages of the cardiac changes. In addition, he made a detailed microscopic study of the hearts of over 100 patients who had died with active rheumatic heart disease and of the left atrial appendages removed from 150 other patients at the time of mitral commissurotomy. The histopathological findings are presented in considerable detail with 162 beautiful reproductions of coloured sections of cardiac tissue illustrating the points made in the text. A study of the text and the slides makes clear the author's claims that the changes in the myocardium, both in man and in rabbits, are really in the muscle cells and not in the fibrous tissue.

Rheumatic heart disease

Objectives
Echocardiographic screening for rheumatic heart disease (RHD) can detect subclinical cases; however, adequate adherence to secondary antibiotic prophylaxis (SAP) is required to alter disease outcomes. We aimed to investigate the adherence to SAP among young people with RHD diagnosed through echocardiographic screening in Fiji and to investigate factors associated with adherence.

Methods
Patients diagnosed with RHD through echocardiographic screening in Fiji from 2006 to 2014 were included. Dates of benzathine penicillin G injections were collected from 76 health clinics nationally from December 2011 to December 2014. Adherence was measured using the proportion of days covered (PDC). Multivariate logistic regression analysis was used to identify characteristics associated with any adherence (≥1 injection received) and adequate adherence (PDC ≥0.80).

Results
Of 494 patients, 268 (54%) were female and the median age was 14 years. Overall, 203 (41%) had no injections recorded and just 33 (7%) had adequate adherence. Multivariate logistic regression showed increasing age (OR 0.93 per year, 95% CI 0.87–0.99) and time since diagnosis ≥1.5 years (OR 0.53, 95% CI 0.37–0.79) to be inversely associated with any adherence. Non-iTaukei ethnicity (OR 2.58, 95%CI 1.04–6.33) and urban residence (OR 3.36, 95% CI 1.54–7.36) were associated with adequate adherence, whereas time since diagnosis ≥1.5 years (OR 0.38, 95%CI 0.17–0.83) was inversely associated with adequate adherence.

Conclusions
Adherence to SAP after screening in Fiji is currently inadequate for individual patient protection or population disease control. Secondary prevention should be strengthened before further screening can be justified.

/pdf/adherence-to-secondary-antibiotic-prophylaxis-for-patients-46xpvnzwhz.pdf

Adherence to secondary antibiotic prophylaxis for patients with rheumatic heart disease diagnosed through screening in Fiji.

Acute rheumatic fever (ARF) rates have declined to near zero in nearly all developed countries. However, in New Zealand rates have not declined since the 1980s. Further, ARF diagnoses in New Zealand are inequitably distributed--occurring almost exclusively in Māori (the indigenous population) and Pacific children--with very low rates in the majority New Zealand European population. With ARF diagnosis, secondary prophylaxis is key to prevent recurrence. The purpose of this study was to identify the perceived enablers and barriers to secondary recurrence prophylaxis following ARF for Māori patients aged 14–21. This study took a systems approach, was informed by patient voice and used a framework method to explore potential barriers and enablers to ongoing adherence with monthly antibiotic injections for secondary prophylaxis. Qualitative interviews were conducted with 19 Māori ARF patients receiving recurrence prophylaxis in the Waikato District Health Board region. Participants included those fully adherent to treatment, those with intermittent adherence or those who had been “lost to follow-up.” Barriers and enablers were presented around three factors: system (including access/resources), relational and individual. Access and resources included district nurses coming to patients as an enabler and lack of income and time off work as barriers. Relational characteristics included support from family and friends as enablers and district nurse communication as predominantly a positive although not enabling factor. Individual characteristics included understanding, personal responsibility and fear/pain of injections. This detailed exploration of barriers and enablers for ongoing secondary prophylaxis provides important new information for the prevention of recurrent ARF. Among other considerations, a national register, innovative engagement with youth and their families and a comprehensive pain management programme are likely to improve adherence to ongoing secondary prophylaxis and reduce the burden of RHD for New Zealand individuals, families and health system.

/pdf/enablers-and-barriers-to-secondary-prophylaxis-for-rheumatic-597bedidbs.pdf

Enablers and barriers to secondary prophylaxis for rheumatic fever among Māori aged 14-21 in New Zealand: a framework method study.

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/1753-6405.12737

Aboriginal children and penicillin injections for rheumatic fever: how much of a problem is injection pain?

Background Rheumatic heart disease (RHD) is a major cause of preventable premature cardiovascular-related death in developing countries. However, information regarding adherence rates and associated factors is limited and inconsistent in Ethiopia.
 Methods
 A cross-sectional study was conducted from August to November 2019 among selected RHD patients on follow-up at four hospitals in Jimma zone. Data were collected using a structured questionnaire. Adherence of RHD patients to secondary prophylaxis in the previous consecutive 12 months was assessed based on the annual frequency of received prophylaxis (monthly injection of benzathine penicillin). Good adherence was considered the patient receiving >80% of the annual dose. The collected data were entered into Epidata 3.1 and analysed using SPSS 23.
 Results
 A total of 253 RHD patients taking prophylaxis were included in the analysis, and of those 178 (70.4%) were female, giving a male:female ratio of 1:2.4. The mean age was 24±11 (6–65) years. About 63% had good adherence to benzathine penicillin prophylaxis. New York Heart Association functional class I and II, rural residence, >30 km from health facility, and duration of prophylaxis >5 years were associated with poor adherence (respectively: AOR 12.6 [95% CI 2.5–63], P=0.016; AOR 6.8 [95% CI 1.9–24.4], P=0.003; AOR 5.5 [95% CI 1.2–26.7], P=0.046; AOR 1.2 [95% CI 1.1–3.2], P=0.021). Leading barriers to good adherence were long distance from the treatment setting (56.9%), followed by lack of money (38%).
 Conclusion
 Patients with class I and II heart failure and those living in rural areas, especially >30 km from a hospital, were identified to be poorly adherent to secondary prophylaxis.

/pdf/rheumatic-heart-disease-patients-adherence-to-secondary-3fvdv8ywd3.pdf

Rheumatic Heart Disease Patients' Adherence to Secondary Prophylaxis and Associated Factors at Hospitals in Jimma Zone, Southwest Ethiopia: A Multicenter Study.

Objectives:To determine the level of adherence and possible barriers to secondary prophylaxis among clients with rheumatic fever in Kingston, Jamaica.Methods:Cross-sectional survey of 39 clients diagnosed with rheumatic fever, receiving penicillin prophylaxis for more than a year using a 22-item self-administered questionnaire on adherence to secondary prophylaxis and knowledge of rheumatic fever. The patients’ records were reviewed to determine the number of prophylaxis injections the patients received for the year 2010.Results:The majority of participants (74%) were females and 51% were adults. Only 48·7% had a high level of adherence. The majority (72%) had low knowledge levels regarding their illness, while only 5% had a high knowledge level score. Most clients (70%) strongly agreed that nurses and doctors encouraged them to take their prophylaxis. However, over 60% reported that they travelled long distances and or waited long periods to get their injections. One-third reported that they miss...

Sheron Boswell Thompson

Papers

Low adherence to secondary prophylaxis among clients diagnosed with rheumatic fever, Jamaica